Key moments, in order
Mania is basically a state of denial of all the sad things depressive people are acutely aware of. The two are opposites, which does not mean they are not the same phenomenon.
People with depressive personality tend to have had significant loss without being helped to grieve it, and tend to believe it is somehow their fault that they are suffering.
Normal grief feels like something happened to you, and that it will pass. In depression the problem feels inside you, and one of the worst things about it is that it feels endless.
Depressive patients are usually good psychotherapy patients because they come in believing the problem is them. They are very reactive to separation and tend to equate separation with rejection.
Two groups need different things. The more empty, hungry group responds very well just to a relationship in which the other person is interested in them. With the self-hating group, the therapist eventually has to call their attention to their go-to automatic self-talk.
Be too supportive with the self-hating kind and they tend to get more depressed. They conclude you are a very nice person who does not get how bad they really are.
It tends to develop in sensitive, highly related children whose parent is critical, unresponsive or absent and cannot meet the child's need for relatedness.
If the other-sex parent seemed powerful and the same-sex parent seemed weak, identity becomes a problem: how do you grow up to feel like a strong version of who you are?
It is not only women. Men can do exactly the same thing: hype up the stereotypical aspects of their own gender in the service of power over someone of the other gender.
Toward the borderline and psychotic end of the spectrum, sexual abuse turns up in the histories of people with hysterical dynamics.
The hysteric is someone pretending to be who they really are. The underlying fear is of being dominated, put down or patronized.
Be very respectful and patient, and do not interpret at the person, because that makes them feel dominated, impinged on or penetrated again.
At the psychotic end there is so much drama all the time that you cannot get near psychotherapy. You do damage control.
In couples, watch for a pursuer-distancer pattern: when she is upset she moves toward him, when he is upset he moves away. If they truly appreciate the difference, he can learn to come toward her and she can learn to give him space.
Since we all have emotional reactions to patients, treat countertransference as data. Feeling a little off, uncomfortable or bored is a cue to get curious: why am I finding myself bored?
In concordant countertransference the patient evokes in you what the patient typically feels. In complementary countertransference you feel what other people felt toward the patient.
You can voice it tentatively. If the patient is conscious only of sadness and you feel angry about someone who hurt them: I get that you are very sad. Is there any anger there? I am feeling a certain kind of anger.
Some patients test you: they treat you the way they were treated, then watch whether you can react differently from the only ways they had as a child.
It has more to do with a controlling parent than with anal fixation, though the worries do center on cleanliness, timeliness and cooperation versus rebellion.
They can be angry only when it feels realistic and justified, so they can be very angry about unfairness. Ordinary anger, being pissed off because they did not get what they wanted, is very hard for them.
They need a therapist who can help them become more comfortable with their emotional life and really question the belief that feeling things is the same as losing control.
Perfectionism here is a defense against fear. Compare obsessive-compulsive people, where it defends against feeling bad, and narcissistic people, where it defends against shame.
OCD symptoms are ego-dystonic: ask why they do it and they get upset that they do. At the borderline and psychotic levels, rituals tend to be ego-syntonic, felt as natural, the only way to be.
A developmental milestone is seeing that two other people can have something between them that is not about you: a triumph over the egocentrism of the early years.
Without reaching that stage, people tend to feel only one side of a relationship at a time, which creates a lot of trouble.
Each moment is a point made in the episode, linked to the second it was said. The topic links open everything the podcast has said on that topic.